Insomnia

What is insomnia?

Insomnia is a sleep disorder. If you have insomnia, you find it hard to fall asleep or stay asleep. Most Australians experience insomnia at some point in their lives, and about 1 in 10 people have at least mild insomnia at any given time. It is more common in females and older people.

Insomnia can include:

• difficulty falling asleep
• waking up during the night and having trouble going back to sleep
• waking up too early

Sometimes people can experience all 3 of these.

You might experience insomnia for a short time, for example if you’re worried or stressed. Sometimes insomnia can become long term (called chronic insomnia disorder). This is defined as having trouble falling asleep or staying asleep at least 3 nights per week, for at least 3 months, along with not functioning well during the day.

What are the symptoms of insomnia?

Symptoms of insomnia include:

• difficulty falling asleep
• waking up a lot during the night
• waking up too early, and not being able to go back to sleep
• not feeling refreshed when you wake up

Insomnia can lead to the symptoms during the day, including:

• tension headaches
• low energy, feeling tired or being too sleepy to do normal activities
• poor memory and concentration
• worrying about sleeping
• feeling irritable, moody or losing motivation and interest in doing things
• feeling restless, being aggressive or impulsive
• feeling sleepy when sitting quietly

People experience insomnia differently, and you might only have some of these symptoms.

What causes insomnia?

There are many different causes of insomnia. In primary insomnia, there is no underlying cause. Secondary insomnia is when it is caused by an underlying condition. There are many factors which can cause or worsen existing insomnia.

Causes of secondary insomnia and worsening of existing insomnia include:

• medical issues — in particular conditions causing chronic pain, hormone changes (such as hot flushes and night sweats during menopause), and breathing, urinary or digestive problems
• sleep disorders — including obstructive sleep apnoea, circadian rhythm disorders caused by irregular sleep patterns, restless legs syndrome and periodic leg movement
• substances — including caffeine, nicotine, alcohol, amphetamines and some medicines
• mental health problems — such as anxiety, depression or other disorders, stress caused by work or financial problems, relationship issues or grief
• poor sleep habits — known as sleep hygiene

Some people have an increased risk of insomnia, including:

• older people
• shift workers

When should I see my doctor?

It is a good idea to see your doctor if you are having trouble sleeping or if you are having problems with your mood, feeling restless in bed or waking up not feeling refreshed.

Keeping a sleep diary is a good way to track your symptoms, which you can share with your health professional.

How is insomnia diagnosed?

Your doctor will ask you about your sleep habits, medicines, how much caffeine and alcohol you consume, and other symptoms you may have, such as pain. They may examine you to rule out underlying conditions that may be causing your insomnia. In some situations, your doctor may refer you for tests at a specialist sleep clinic.

How is insomnia treated?

There are many treatments for insomnia. Your doctor will choose a treatment plan based on your situation. Treatments include one or more of the following:

Treating an underlying condition

If your insomnia is caused by an underlying condition such as:

• pain
• hormone changes
• digestive problems
• mental health problems
• other sleep disorders, such as sleep apnoea

Your doctor may suggest treating those conditions or recommend investigations to find other ways to improve your insomnia symptoms.

If a medicine is causing the insomnia, your doctor may be able to give you a different medicine or help you cut down on the dosage.

Sleep hygiene

Good sleep hygiene includes forming good habits that will help you sleep well. If your insomnia is caused by poor sleep hygiene, the first step in treatment is to learn to adopt healthy sleep habits and change any lifestyle factors that may contribute to the insomnia.

Sleep hygiene habits include:

• Keep regular sleep patterns. Try to go to bed and wake up at around the same time every day and avoid daytime naps. Don’t spend too long in bed — most people should not stay in bed for more than 8 ½ hours. Staying in bed for longer can lead to broken sleep.
• Make sure your bedroom is comfortable. It should be quiet and dark, not too hot or too cold. Consider removing clocks from your bedroom, so you don’t keep checking the time. Avoid screens in your bedroom, and don’t use screens for one hour before going to bed.
• Cut out nicotine, reduce or cut out alcohol and limit caffeine to mornings only.
• Exercise regularly, but not in the evening.
• If you can’t sleep, go to another room and engage in a quiet activity (such as reading) until you feel tired, and then try again.
• Do something you find relaxing before bed.
• Try to manage anything that is worrying you earlier in the day, rather than at bedtime.

Relaxation techniques

Learn to relax your body and mind before bed. This can help you let go of worries and prepare your body for sleep. Breathing exercises, progressive muscle relaxation and meditation can be useful techniques before sleep.

Cognitive behaviour therapy (CBT)

Cognitive behaviour therapy (CBT) is usually the first line of treatment if sleep strategies and relaxation have not helped you. CBT is a treatment based on the idea that how you think and act affects how you feel. It is usually provided by a psychologist and can be done individually or in a group. CBT is effective for insomnia, anxiety and depression.

Medicines

Prescription medicines

In the case of chronic insomnia, where other treatment methods have not helped, doctors may prescribe medicine. Sleeping tablets are less effective than CBT and are not a cure for insomnia. They can be useful for a short period of time, but they become less effective if you take them too often. Long-term medicine use can also lead to addiction and side effects.

Side effects could include:

• night wandering
• agitation
• excessive drowsiness
• impaired thinking
• balance problems
• allergic reactions

Sometimes, sleeping tablets can make insomnia worse, especially if you take them regularly.

Types of sleeping pills that doctors may prescribe include:

• Sedatives are the most common sleeping pills used in Australia. They include temazepam, zopiclone and zolpidem. These medicines work by making the part of your brain responsible for sleeping more active. These should be used for less than 4 weeks to reduce the chance of side effects and addiction.
• Suvorexant works by making the ‘awake’ pathways in your brain less active. It can be used for long periods of time to treat chronic insomnia for people who wake in the night and struggle to stay asleep.
• Antihistamines are used to treat allergies. Those which have a sedating side effect are not recommended to be used as a sleeping pill.
• Antidepressants and antipsychotics are used to treat mental health conditions and are not recommended to treat primary insomnia.

Another option your doctor may recommend is melatonin, a hormone that controls the body’s night and day cycles. It can be used as a sedative, to make you feel sleepy or to reset your internal body clock. It is taken as pills. The best time to take melatonin is 1 hour before you go to bed. You should not take melatonin before you drive or operate machinery, as it can make you sleepy.

Over-the-counter sleep aids

You can buy herbal remedies over the counter that are promoted to help people sleep. These include kava, valerian, passionflower, hops, sour date, mimosa, lavender, California poppy and chamomile.

There is little scientific evidence about whether these remedies work and about the consequences of taking them for a long time.

It is important to talk to your doctor before you take a sleeping aid, including any over-the-counter or herbal remedies, as they may interact with your other medicines. Make sure you follow the instructions on the label carefully and do not take them for a long period of time. You should avoid alcohol when you are taking over-the-counter sleeping aids.

Other treatments

• Light therapy: uses bright lights to change your internal body clock and improve sleep.
• Sleep restriction: this method reduces your sleep hours, causing sleep deprivation; once sleep has improved, you can go back to sleeping normal hours.

What are the complications of insomnia?

Insomnia also causes a range of problems that can occur during the day, and can make it difficult to function normally. They include:

• poor concentration
• making mistakes or forgetting things
• anxiety or depression (these issues can also cause insomnia)
• tension headaches
• digestive symptoms

Being overtired can increase your risk of making mistakes or having an accident. Research has shown that severe sleep deprivation can affect your ability to drive as much as alcohol.